Depression stress and anxiety in

SLE

Martha Rodríguez, MD
Assistant Professor of Clinical Pediatrics
Indiana University School of Medicine
Section of Pediatric Rheumatology
Riley Hospital for Children at Indiana University Health
 Depression in chronic disease

• Chronic disease has a

detrimental impact on an
individual’s mental health.
• We have learned that the
relationship between
chronic physical disease and
mental illness is
bidirectional
 Depression in chronic disease
• The Healthy People 2020 report from the
United States (US) Department of Health and
Human Services states that “mental health
disorders have a serious impact on physical
health and are associated with the prevalence,
progression, and outcome of some of today’s
most pressing chronic diseases.
 Systemic lupus erythematosus
• Systemic lupus erythematosus (SLE) is a
multisystem, autoimmune disease in which
the immune system mistakenly attacks the
body
• SLE has frequent psychological comorbidities,
of which depression and anxiety are two
common manifestations
 Depression and SLE
• It has been reported that there were 2 times
higher prevalence of depression in SLE
patients compared to the general population.
• Approximately one-third of all people with
lupus experience depression and anxiety.

Bogdanovic G, Stojanovich L, Djokovic A, Stanisavljevic N. Physical Activity

Program Is Helpful for Improving Quality of Life in Patients with Systemic
Lupus Erythematosus. Tohoku J Exp Med. 2015;237(3):193–9.
 Depression and SLE
• There is evidence that youth with SLE have
disproportionately higher rates of suicidal
ideation compared to healthy controls with
reported rates of suicidal ideation ranging
between 14-34%

Knight A, Weiss P, Morales K, Geredes M, Gustein A, Vickery M, et al. Depression and anxiety and
their association with healthcare utilization in pediatric lupus and mixed connective tissue disease

patients: a cross-sectional study. Pediatr Rheuamtol Online J. 2014;12:42.

 Etiology
• Organic: autoantibody
mediated vascular or
neuronal injury seems
to play a major role
Etiology
 Predictors of depression

• Appearance concerns.
• Inadequate pain/disease
control.
• Work and activity
limitations.
• Social isolation.
• Uncertainty about the
future.
• Difficulty with family
relationships.
Diagnosis
PHQ-9 Interpretation
GAD 7 interpretation
Diagnosis
 Barriers for Mental Health Screening
Perceived by Pediatric Rheumatologists
• Limited staff resources to screen.
• Limited time/ space during the encounter.
• Limited staff resources to follow up results of screening.
• Lack of institutional support.
• Provider lack of knowledge about mental health.
• Patient willingness to be screened.
• Parent willingness to have child screened.

(Knight, 2016)

Up to 75 % of symptomatic patient with

SLE had not had mental health
evaluation
 Complications
• Increased incidence of cardiovascular
diseases.
• Myocardial infarction.
• Suicidal ideation.
• Physical disability.
• Decreased quality of life.
• Higher risk of premature mortality .
• Poorer disease control.
Relation between disease stress
and depression
How do you combat a lupus
depression?
 Stages of grief with a diagnosis
• Aim for Acceptance of Your Lupus Diagnosis
Stage 1 – Denial and isolation:
Stage 2 – Anger “Why me?”
Stage 3 – Bargaining
Stage 4 –Depression
Stage 5 – Acceptance
 Stage 1 – Denial and isolation:

• No, not me!

• This can’t be happening to me.
• A mistake has been made in the diagnosis.
• Is a type of shock absorber.
• Denial lets us cope with only what we can
handle.
 Stage 2 – Anger “Why me?”
• Feelings of anger, rage, jealousy and hatred.
• The person's anger is directed outward. It can
extend from the immediate family, to medical
professionals, to friends as well as to God.
• It is important to remember that underneath
the anger is pain.
 Stage 3 – Bargaining
• Patients may bargain about things like pain,
whether physical or emotional.
• Guilt comes along with bargaining. People
often go down the path of "What if.." or "If I
only…", finding fault in themselves and things
they have done.
 Stage 4 –Depression
• Depression replaces the anger and the
attempts at bargaining.
• Does not advise trying to cheer up or calm the
individual steeped in depression.
• It is necessary to support the individual with
compassion and understanding
 Stage 5 – Acceptance
• It is about accepting the new reality.
• In this stage the patient ceases his or her fight
against fate/diagnosis.
 Talk With Your Doctor About
Depression and Lupus

• Your doctor can assess,

diagnose, and help you
decide what kind of
treatment is best
 Coping Strategies
• Trust in Divine Help
• Trust in Medical Help
• Conscious Way of Living
• Positive Attitudes. Positive self-talk
• Distraction
• Relaxation
• Seeking for social support
 Keep Self-Talk Positive, Avoid
Negative Self-Talk
• “What you tell yourself is more important
than what others say about you” Grusd.
• List the people and things in your life for
which you are grateful.
• Replace negative, self-defeating inner
language with truthful, productive thoughts,
such as: “I feel lousy, but I have many
blessings
• Use imagery (thinking about positive
experiences you have had)
 Surround Yourself With
Supportive People
• It’s important to surround yourself with
positive people who are willing to be
supportive -- even if this means making some
new friends
• LupusConnect 24/7 Access to support and
community
• Lupus support groups in Indiana
 Surround Yourself With
Supportive People
• Online
Monday, October 29, 7:00-8:00 PM
Process for registering
Facilitators: Kayla Lockwood and Samantha
Walker
Email: lupusinonline@gmail.com
 Surround Yourself With
Supportive People
• For more information on support groups, visit
Find Help or for questions regarding any of
our monthly meetings, please call
800.948.8806 or send an email to Debbie
Campbell.
 Find ways to reduce pain
• Yoga
• Tai Chi
• Pilates
• Acupuncture
• Biofeedback
• Meditation
• Chiropractic care
• Exercise
 Natural therapies

• Acupressure
• Hot and cold therapy
• Massage therapy
• Mind-body therapies
 Improve your sleep habits
• Get seven to eight hours of sleep in a 24-hour
period.
• Do aerobic exercise every day, such as brisk
walking—or whatever you can manage.
• Avoid caffeine, nicotine, and alcohol several
hours before bedtime.
• Establish a regular relaxing bedtime routine
 Improve your sleep habits
• Know which medications keep you from
sleeping and take those early in the day.
• Have a good mattress, comfortable bed linens,
the right room temperature, and the right
amount of darkness.
• Limiting daytime naps to 30 minutes.
 Discover the values of
volunteerism
• Volunteerism can provide real emotional
benefits. Helping with a charitable cause that
is meaningful to you can create social,
supportive connections. Helping others can
have a positive impact on your sense of well-
being
 Strive to accept the new “you.”
• Pace yourself, and don’t feel badly about
delegating some of your responsibilities.
• Ask for help, and accept help graciously.
• Focus on what you have and what you can do,
rather than on what you don't have and can’t
do.
 Negative coping strategies
• Negative self-talk
• Negative daily mood and more daily stressful
events significantly predicted increased
reports of fatigue, stiffness, pain and cutting
back on daily activities.
 Negative coping strategies
• Lack of social support network
• Emotion-based focusing ( when patients
focus on the negative aspects of the symptoms
and avoiding active coping while internalizing
negative feelings).
 Negative coping strategies
• Rumination is the focused attention on the
symptoms of one's distress, and on its
possible causes and consequences, as
opposed to its solutions.
• Catastrophizing is an irrational thought
believing that something is far worse than it
actually is.
 Psychological interventions
• Antidepressant medications
• Anti-anxiety medications
• Psychotherapy: can help you learn to
understand your feelings, your illness, and
your relationships, and to cope more
effectively with stress
• Cognitive behavioral therapy
 Cognitive Behavioral Therapy
• The most successful psychological
interventions for improving pain in patients
with chronic diseases.
• Incorporate normalization of the patient’s
experience through education regarding the
condition and its impact, training in specific
strategies, managing disease-related and
other stressors, providing guidance on
developing and implementing a long-term
plan for self-managing the condition.
 Things to work on
• More disease-specific knowledge.
• Self-management strategies .
• Meaningful social support .
 Things to work on
• SLE may limit some of the things you can do,
but it doesn’t have to control your life Keep a
positive attitude!!!
• Don’t dwell. How often do you think about
your symptoms? The amount of time you
spend thinking about your symptoms has a lot
to do with how much discomfort you feel. Try
to focus your energy on how to ease your
symptoms
 Things to work on
• Think about pain differently. Think of pain as
your body’s message to do something
different. For example, if your pain is worse
after sitting for a period of time, your body
may be telling you to get
up and move around.
 Things to work on
• Shift your focus. One way to take your mind
off your symptoms is to focus on something
else, like an enjoyable activity. Doing things
that make you laugh, listening to your favorite
music, talking to a friend.
• This can help your body release feel-good
chemicals that will ease your symptoms.